Dear Jonny

Thank you for coming to speak to us last week. In light of recent media exposure the prospect of meeting 20 angry doctors and specialists must have been daunting. Your DM to me that you were “looking forward to it” was a surprise, but it strikes me that you are up to any challenge.

It is appropriate to address you via an open letter because this interaction began in the realm of social media, and I believe we should continue dialogue here in the light of transparency in an industry that affects every single one of us. These issues are not purely yours or mine, but also the consumers, because ultimately every cent saved or spent comes out of their pockets. There is considerable public interest in our debate and the differences we doctors have with medical aids. Let the people be informed and let them decide.

The worst possible end result of this meeting would be a “business as usual” approach on your part, a successful executive mission to calm us, the restless workers. There is still too much anger for that, and I for one will not be placated by anything other than visible and transparent action.

There were several issues debated on the night, among them the close relationship between Discovery Health Medical Scheme (DHMS), and Discovery Health, and the veracity of the Deloitte report, that we can agree to disagree on and put aside. They are neither here nor there, and not really worth getting into. I would however love to hear a publicly expressed and independent opinion from one of DHMS’s trustees on these issues at least once in my lifetime.

Far more important is what is and is not working in the doctor-funder relationship. It was stated very emphatically in the meeting that the real reason doctors do not like Discovery Health and DHMS is that we are coerced into signing contracts for sub-economic remuneration in order to be paid directly for our services and to avoid seeing our own patients run off with a tidy windfall in their own accounts for work we have done. You may not call it coercion, but I think we, the “coerced”, should be the judges of that. Even if the above scenario happens only once in every 20 transactions, it gets 100% of our attention.

The second obstacle is Discovery Health’s committed resistance to balanced or split billing, where doctors bill the medical aid for the amount covered by the member’s policy, but present a second account for the balance not covered by DHMS, based on the belief that this prejudices your members. While I can understand you want to avoid your members having to pay over and above their premiums, this belief is ironic in the context where your members are subjected to co-payments anyway for many procedures and treatments based on Discovery Health’s own policies and limitations. I don’t understand why the one should be acceptable and the other not?

Another problem clearly evident from our meeting is that policy made at executive level in Discovery Health is not being passed on to the lower-tier managers and case advisers who deal directly with doctors. Two cases in point — a general surgeon being asked to write a motivation for doing a mastectomy for a patient with breast cancer. As you know, in terms of the Health Professions Council of South Africa (HPCSA) rulings, no specialist is required to give a motivation for any treatment. Why is Discovery Health still asking? And men with painful gynaecomastia? If you say surgery in these patients is most definitely covered by DHMS, why are authorisations being refused, not just once, but time over and again? There appears to be a clear failure of corporate governance and quality control in the direct dealings with doctors and over authorisations. In other words, please treat us as professionals in accordance with the rules set by the Council for Medical Schemes and HPCSA.

There is a comfortable fourth party in this relationship — the broker who sells the medical-aid policies on your behalf — R65 a month per member is not a huge commission, but over years it mounts up, and the broker should be expected to be the person who deals with members’ medical-aid problems directly, not the doctor. So how many DHMS members know who their brokers are, considering 3 in 4 have been signed up by their employers? Agreeing with this point, as you have with me privately, is on its own not enough. Discovery Health, DHMS and brokers must be responsible for educating members so that they know the limitations of the policies they have bought and for helping them through an increasingly complex quagmire of health insurance so that doctors and patients are not stonewalled by denials of treatment. It’s not our job to do that for you.

The biggest “wow” moment from the meeting for me is information you provided, that a 10% reduction in downstream costs of patient care like unnecessary tests, medications, hospitalisations and procedures, would allow a 40% increase in members benefits without an increase in their premiums. The message is both alarming and encouraging. It suggests that there is potential to correct this situation. The problem is that the ethical and responsible doctors have no room to manoeuvre, and that your systems allow no recognition of them.

Suggestions have been offered as to a way forward. Discovery Health sits in the pound seats at the moment, a very successful and powerful company with the ability to make a positive change for health professionals and consumers to fix our industry at very little risk.

Discovery Health’s profits, a subject we did not dwell on at the meeting, at the moment suggest you do not have to do anything — the money is rolling in. Is Discovery Health committed enough to this industry to try to fix it? To take a risk or two?

The move is yours to make.





Martin Young

Martin Young is an ENT surgeon living an idyllic life in Knysna. He is a firm believer that "the unexamined life is not worth living", writes for a hobby and is happy to speak truth to power

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